Release of Medical Information

Date

Patient Name

Date of Birth

Address

I hereby authorize:

Marjaneh Rouhani, MD
300 Country Pine Lane
Battle Creek, MI 49015

To release to:

Name of Person or Agency

Address

Information to be disclosed:

All medical information

Specific medical information

Please describe:

Purpose and need for such disclosure:

I hereby consent to the release of any medical information, which may include the following: psychiatric, alcohol and/or drug abuse records, AIDS, AID-related complex (ARC) and HIV infection.
I understand that this authorization may be withdrawn by me at any time. Revocation of this
authorization will not affect any information already released.

Patient Signature

Date

Witness

Date